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Signature of the employeeIndianHyderabadEmployee Signature

1 FORM NO. 12B[See rule 26A]Form for furnishing details of income under section 192(2) for the year ending 31st March, ..Name and address of the employeePermanent Account statusParticulars of salary as defined in section 17, paidor due to be paid to the employee during the yearSerialName andTAN of thePermanentPeriod ofTotal amountTotal amountValue ofTotal ofAmountTotal amountRemarksNumberaddress ofemployeer(s)Accountemploymentof salaryof houseperquisitescolumnsdeductedof tax deductedEmployer(s)as allottedNumber ofmentexcludingrent allow-and amount6, 7in respectduring theby thetheamountsance, convey-of accre-and 8of lifeyear (encloseITOemployer(s)required toance allowancetion toinsurancecertificatebe shown inand other allow-employee spremium,issued undercolumns 7ances toprovidentprovidentsecgtion 203)and 8the extentfundfundchargeableaccountcontri-to tax(give detailsbution, etc.[See sec-in theto whichtion 10(13A)Anne-sectionread withxure)80C$rule 2 Aappliesand section(Give10(14)details) of the employeeVerificationI.]

of house perquisites columns deducted of tax deducted Employer(s) as allotted Number of ment excluding rent allow-and amount 6, 7 in respect during the by the the amounts ance, convey-of accre-and 8 of life year (enclose ITO employer(s) required to ance allowance tion to insurance certificate be shown in and other allow-employee ’ s premium ...

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Transcription of Signature of the employeeIndianHyderabadEmployee Signature

1 1 FORM NO. 12B[See rule 26A]Form for furnishing details of income under section 192(2) for the year ending 31st March, ..Name and address of the employeePermanent Account statusParticulars of salary as defined in section 17, paidor due to be paid to the employee during the yearSerialName andTAN of thePermanentPeriod ofTotal amountTotal amountValue ofTotal ofAmountTotal amountRemarksNumberaddress ofemployeer(s)Accountemploymentof salaryof houseperquisitescolumnsdeductedof tax deductedEmployer(s)as allottedNumber ofmentexcludingrent allow-and amount6, 7in respectduring theby thetheamountsance, convey-of accre-and 8of lifeyear (encloseITOemployer(s)required toance allowancetion toinsurancecertificatebe shown inand other allow-employee spremium,issued undercolumns 7ances toprovidentprovidentsecgtion 203)and 8the extentfundfundchargeableaccountcontri-to tax(give detailsbution, etc.[See sec-in theto whichtion 10(13A)Anne-sectionread withxure)80C$rule 2 Aappliesand section(Give10(14)details) of the employeeVerificationI.]

2 , do hereby declare that what is stated above is true to the best of my knowledge and today, the .. day of..Place .. Signature of the employeeANNEXURE[See column 8 of Form No. 12B]Particulars of value of perquisites and amount of accretion to employee s provident fund accountName and address of the employeePermanent Account No..Period: Year ending 31st March, ..Name of theTAN/PAN of theValue of rent free accommodation or value of any concession in rent for the accommodation provided by the employer (give basis of computation)employeeemployer[See rules 3(a) and 3(b)Where accommodation is furnishedWhereValue as ifCost of furniturePerquisite value ofTotal of columnsRent, if any, paidValue ofaccommodationaccommodation(including televisionfurniture (10% of4 and 6by emplyeeprequisiteis unfurnishedis unfurnishedsets, radio sets,column 5) OR(column 3 minusrefrigerators, otheractual hirecolumn 8 orhousehold appliancescharges payablecolumn 7 minusand air-conditioningcolumn 8 as mayplant or equipment)be applicableOR hire charges, ifhired from a thirdparty123456789(Contd.))]

3 On next page)ANNEXURE(Contd.)Whether any conveyanceRemuneration paid byValue of free orEstimated value of anyEmployer s contributionInterest credited to theTotal of columns 9 to 15has been provided by theemployer for domesticconcessional passages onother benefit or amenityto recognised providentassesse s account incarried to column 8 ofemployer free or at aand/or personal serviceshome leave and otherprovided by the employer,fund in excess of 10% ofrecognised providentForm No. 12 Bconcessional rate orprovided to the employeetravelling to the extentfree of cost or atthe employee s salaryfund in excess of the ratewhere the employee is(give details) [See rule 3(g)]chargeable to tax (giveconcessional rate not[See Schedule IV Partfixsed by the Centralallowed the use of one ordetails)[See rule 2B readincluded in the precedingA]Government [Seemore motor cars ownedwith section 10(5)(ii)]columns (give details), IV Part A]or hired by the employer,supply of gas, electricity orestimated value ofwater for householdperquisite (give details)consumption, free[See rule 3(c)]educational facilities,transport for family, etc.

4 [See rules 3(d), 3(e)and 3(f)] of the employ


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